Cytological Analysis of Small Branch-Duct IPMNS Provides a More Accurate Risk Assessment for Malignancy Than Symptoms.
Jill Ono, Kurt Yaeger, Muriel Genevay, Mari Mino-Kenudson, William R Brugge, Martha B Pitman. Massachusetts General Hospital, Boston; University Hospitals of Geneva, Switzerland
Background: The Sendai guidelines for management of patients with clinically suspected branch-duct IPMN recommend surgical resection for small (< 30mm) cysts with either a dilated main pancreatic duct (MPD) > 6mm, a mural nodule (MN) or symptoms. Cytological evaluation is controversial and a risk factor only when “positive”. Our historical experience of aspirating almost all pancreatic cysts has shown that cytology adds significant value to the preoperative management of these patients. We evaluated the accuracy of cytology relative to symptoms as a risk factor for surgical triage in a cohort of small branch-duct IPMN without evidence of a dilated MPD or MN.
Design: We retrospectively reviewed clinical, radiological and cytological data of 31 histologically confirmed small branch-duct IPMN of the pancreas without evidence of a dilated MPD or a MN and with adequate EUS-FNA fluid for evaluation. Clinical and radiological parameters were retrieved from medical records. Symptoms were recorded as present or absent. Cytology with high-grade atypical epithelial cells or malignancy (HGA) was considered true positive, and their absence as true negative for predicting histology of high-grade dysplasia or invasive carcinoma in resection specimens. Performance characteristics of sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were calculated for clinical symptoms and cytology for appropriate surgical triage.
Results: There were 31 branch-duct cysts with a mean size of 18.7mm in 22 females and 9 males with an average age of 67 years; 55% were symptomatic, and 25.8% cyst fluids contained HGA. The table below compares the performance characteristics of surgical triage based on symptoms versus cytology with HGA.